Chronic Wounds as Biofilm Ecosystems: Modernizing Microbiology Beyond Planktonic Paradigms

Significance: Chronic wound infections, including diabetic foot infections, are increasingly recognized as biofilm-associated polymicrobial ecosystems rather than simple planktonic infections. However, routine microbiological workflows remain largely optimized for acute infections, creating a mismatch between laboratory diagnostics and the biological organization of chronic infection. Recent Advances: Growing evidence from biofilm biology, microbial ecology, and molecular microbiology has demonstrated that chronic wound infections are characterized by structured microbial communities, physiological heterogeneity, and enhanced antimicrobial tolerance. Advanced diagnostic approaches have improved understanding of microbial diversity and biofilm-associated persistence beyond what is captured by conventional culture alone. Critical Issues: Conventional microbiological workflows may incompletely resolve the microbial populations most relevant to chronicity, recurrence, and treatment failure. Key limitations include sampling strategy, tissue processing, incubation conditions, anaerobic recovery, and reliance on planktonic susceptibility testing. The discrepancy between minimum inhibitory concentration–based testing and biofilm-associated antimicrobial tolerance highlights an important gap between laboratory assessment and infection biology. Future Directions: Modernization of chronic wound microbiology requires a transition from pathogen-centered planktonic models toward biofilm-aware, ecosystem-oriented approaches. Integration of optimized sampling, culture-based diagnostics, selective molecular tools, surgical source control, and antimicrobial stewardship may improve diagnostic resolution, support more rational antimicrobial use, and enhance long-term clinical outcomes. Lorenzo Drago, PhD